The Social Worker is assigned to the Intensive Management Patient Aligned Care Team (IMPACT) serving San Francisco VA Health Care System primary care clinic and the Community Based Outpatient Clinics CBOCs. IMPACT serves as an adjunctive arm of each PACT. IMPACT works to extend PACT support into the community setting. The caseload consists entirely of complex and often high-risk patients, including high utilizers; persons with dementia with extreme lack of social support; Veterans with high CAN scores indicating the highest risk of hospitalization or death. The role of the Social Worker is to provide community based social work services to the Veteran and family/support system when indicated and to collaborate and communicate with the Veteran, support system, IMPACT and primary PACT teams and/or Mental Health Treatment Coordinator (MHTC) to assess, intervene and promote implementation of a unified, comprehensive treatment plan. The goal is stabilization, decrease in high utilization and increase-Veteran/provider satisfaction. Social work activities include: home visit; assessing and monitoring coping in the community including identifying and responding to crisis and risk; accompanying Veterans to appointments in the community that facilitate linkage to support services and benefits; identifying need for and facilitating transition to higher levels of care when indicated; and visits via telehealth. Must be able to drive a motor vehicle to accomplish some of these tasks. Proactive and regular communication with IMPACT and PACT members is critical to the goal of a coordinated, ongoing treatment plan. Work Schedule: Monday through Friday, 8:00am to 4:30pm, Telework: Occasional as determined by supervisor Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.